MANAGED CARE FOR CONGESTIVE-HEART-FAILURE - INFLUENCE OF PAYER STATUSON PROCESS OF CARE, RESOURCE UTILIZATION, AND SHORT-TERM OUTCOMES

Background Although health maintenance organizations (HMO) are insurin g an increasing number of Americans, there are concerns that cost-redu ction strategies may limit access to medical care or jeopardize its qu ality. This study was conducted to examine the influence of insurance payer status on the process of care and resource utilization among pat ients hospitalized for congestive heart failure (CHF). Methods and Res ults Administrative information on all 1995 New York State hospital di scharges assigned ICD-9-CM codes indicative of CHF in the principal di agnosis position were obtained from the Statewide Planning and Researc h Cooperative System database. The following were compared among patie nts with HMO, indemnity, Medicaid fee-for-service, and Medicare fee-fo r-service insurance coverage: demographics, comorbid illness, process of care, length of stay, hospital charges, mortality rate, and CHF rea dmission rate. A total of 43,157 patients were identified (HMO, 1322; indemnity, 4350; Medicaid, 3878; Medicare, 33 607). Noninvasive proced ures were used with similar frequency, whereas greater use of invasive techniques was observed among HMO and indemnity patients. After adjus tment for patient characteristics and hospital type and location, HMO care was associated with shorter length of stay and lower hospital cha rges, the tatter partially explained by fewer hospital days. Medicaid patients had the longest length of stay, greatest hospital charges, an d highest CHF readmission rate. The adjusted risk of death during the index hospitalization did not vary among insurance groups. Conclusions Though insuring only a small proportion of New Yorkers hospitalized f or CHF, managed care plans provide similar access to clinical services while generating fewer charges. Whether these observed differences in short-term outcomes derive from patient mix or quality of care is unc ertain and deserves wider prospective study.